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Perioperative Nursing: Patient Management from Ward to OT and Back

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PHASE 1 - PREOPERATIVE PATIENT IDENTIFICATION

A. Bedside Identification (Ward)

1. Full legal name (ask the patient to state it - do not read and ask "Are you Mr. X?")
2. Date of birth
3. Medical Record Number (MRN) / Hospital ID
4. ID wristband verification - cross-check wristband against:
   • Surgical consent form
   • Theatre list / booking form
   • Case notes / medical records

"Identifying the patient is the first step when evaluating a patient preoperatively, typically done with legal name, date of birth, and medical record number." - Barash Clinical Anesthesia, 9e, p. 1744

B. Preoperative Nursing Checklist (Ward Nurse Completes Before Shifting)

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PHASE 2 - SURGICAL SITE MARKING

Who Marks?

• The operating surgeon marks the site - this is non-delegable
• Done while the patient is awake and can confirm

How to Mark?

• Use a permanent marker (not easily washed off by prep solutions)
• Mark should be at or near the incision site
• For laterality procedures (left/right limb, eye, kidney): mark the correct side with an unambiguous mark (usually "YES" or initials)
• Bilateral, midline, and single-organ procedures: site-specific marking policies apply

Nurse's Role:

• Witness and document that marking has occurred
• Include in pre-op nursing checklist: "Surgical site marked: Yes / No / Not applicable"
• If the patient arrives in OT without a mark - stop the procedure and return the patient or call the surgeon

From the WHO Surgical Safety Checklist Sign-In: "The surgical site is marked, or site marking is not applicable." - Sabiston Textbook of Surgery, p. 146-147

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PHASE 3 - SHIFTING THE PATIENT TO OT (TRANSFER)

Nursing Actions at Ward:

1. Recheck identity and wristband
2. Confirm final NPO status
3. Check all IV lines, catheter, drains are secure
4. Record pre-operative vital signs:
   • Temperature (T)
   • Pulse rate (PR) - rate, rhythm, volume
   • Blood pressure (BP) - both arms if cardiac risk
   • Respiratory rate (RR)
   • SpO2 (oxygen saturation)
   • Blood glucose (if diabetic or ordered)
   • GCS/consciousness level
5. Ensure patient notes, X-rays, consent forms, investigation reports are with the patient
6. Administer pre-medication if due (document time)
7. Position patient safely on trolley with side rails up

Ward-to-OT Handover (Verbal + Written):

• Time of transfer
• Vital signs at time of transfer
• Name of ward nurse handing over
• Name of OT nurse receiving
• Checklist items verified

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PHASE 4 - RECEPTION INTO OT (OT NURSE TAKEOVER)

OT Reception Nurse Actions:

1. Re-verify identity: Confirm with patient (if conscious), wristband, theatre list
2. Check consent: Signed, dated, correct procedure and site stated
3. Verify site marking: Present and legible
4. Complete pre-operative OT checklist (separate from ward checklist):
   • Wristband present
   • Consent checked
   • Allergies confirmed
   • Relevant imaging available in OT
   • Prosthetics/dentures removed
   • Antibiotic prophylaxis ordered/given or scheduled
5. Record vital signs on OT record (baseline in OT environment)

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PHASE 5 - WHO SURGICAL SAFETY CHECKLIST (THREE STEPS)

SIGN IN - Before Induction of Anaesthesia

• Patient confirms: identity, procedure, site, and consent
• Surgical site is marked (or marking not applicable)
• Pulse oximeter on patient and functioning
• Known allergies confirmed with all team
• Airway assessment done; appropriate equipment available
• Risk of significant blood loss addressed (IV access/fluids planned)

TIME OUT - Before Skin Incision

• All team members introduced by name and role
• Patient identity, surgical site, and procedure confirmed aloud
• Surgeon states anticipated critical steps, expected duration, and blood loss
• Anaesthesiologist states patient-specific anaesthetic concerns
• Nursing staff confirms sterility, instrument count, equipment availability
• Antibiotic prophylaxis confirmed given within 60 min of incision
• Relevant imaging displayed and verified for correct patient

SIGN OUT - Before Patient Leaves OT

• Procedure name as recorded
• Instrument, sponge, and needle counts complete
• Specimen labelled correctly (patient name included)
• Equipment issues noted for follow-up
• Surgeon + nurse + anaesthesiologist review: key recovery concerns for this patient

"The surgeon, nurse, and anesthesia professional review aloud the key concerns for the recovery and care of the patient." - Sabiston Textbook of Surgery (BOX 9.1), p. 147

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PHASE 6 - INTRAOPERATIVE NURSING RESPONSIBILITIES

• Maintain sterile field (scrub nurse)
• Count instruments, sharps, sponges before incision and before closure
• Document all events, implants, specimen details
• Monitor patient safety: positioning, pressure area protection, diathermy pad placement
• Record anaesthetic medications as instructed
• Label all syringes and infusions
• Communicate any deviation from plan to surgeon/anaesthesiologist

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PHASE 7 - SHIFTING PATIENT FROM OT TO RECOVERY ROOM (PACU)

Before Transfer from OT:

1. Sign Out checklist completed (see above)
2. Anaesthesiologist confirms patient is:
   • Airway maintained (spontaneous breathing or intubated as planned)
   • Haemodynamically stable
   • Reversal of neuromuscular blockade confirmed (if applicable)
3. Dressings secure, drains/catheters labelled
4. Final intraoperative vital signs recorded
5. Patient transferred to trolley safely with all lines, monitors temporarily maintained

OT-to-Recovery Handover (OT Nurse + Anaesthesiologist → Recovery Nurse):

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PHASE 8 - RECOVERY ROOM (PACU) NURSING TAKEOVER

Immediate Recovery Room Assessment (on arrival):

1. Airway - patent, self-maintaining? Position (lateral if sedated)
2. Breathing - rate, depth, SpO2 on oxygen
3. Circulation - BP, HR, capillary refill
4. Consciousness - AVPU / GCS
5. Pain score (NRS 0-10 or FLACC for non-verbal)
6. Nausea/vomiting assessment
7. Temperature
8. Wound and drain site check
9. IV lines patent, fluids running as prescribed
10. Catheter draining, colour and volume of urine

Vital Signs Monitoring Frequency (PACU):

• Every 5 minutes for the first 15 minutes
• Every 15 minutes thereafter until discharge criteria met
• Document each set in the PACU chart

Aldrete Score (PACU Discharge Scoring):

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PHASE 9 - RECOVERY ROOM TO WARD HANDOVER (FINAL)

1. Verbal SBAR handover at bedside
2. Full post-operative vital signs documented and signed
3. PACU chart transferred with patient
4. Outstanding analgesia, antiemetic, and fluid orders checked
5. Any post-operative instructions from surgeon communicated
6. Drain output, urine output totals documented
7. Time of transfer and receiving nurse signature

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Summary: Vital Signs - When and What to Record

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Key Principles Underpinning All of the Above

• Never proceed with wrong/missing ID - stop, clarify, escalate
• Structured handovers prevent errors - verbal + written, both required
• WHO Surgical Safety Checklist reduces mortality - from 1.5% to 0.8% in landmark studies (Sabiston Textbook of Surgery, p. 145)
• The Joint Commission Universal Protocol mandates time-out before every invasive procedure
• The WHO Surgical Safety Checklist Implementation Manual is the global standard reference